Bodyscapes Patient Form
Please complete all twelve sections of this form (20 minutes) and click "Submit". If you wish to save and continue the form later, click "Save" (located at each page break). A pop up box from Jotform will appear. Input your email and you will receive an email with your form to complete at your convenience.
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Month
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1. General Information
Name
*
First Name
Last Name
Date of birth
*
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Month
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Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
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Area Code
Phone Number
Email
*
example@example.com
Emergency contact and phone number
How did you hear about Bodyscapes?
Have you ever received acupuncture before?
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2. Primary Health Concerns
What is your primary health condition you would like to be treated for?
*
Onset of condition and cause (if known):
Has this condition been diagnosed by a medical doctor and are you currently under the care of a physician for this condition?
What makes it worse?
What makes it better?
Does your condition interfere with any of the following?
Work
Sleep
Walking
Sitting
Standing
Bending
Stretching
Recreation
Relationship
Sexual
Social life
Emotions
Check all that you are interested:
Pain relief
Preventative care
Nutrition
Herbal therapy
Maintenance care
Performance care
Stress relief
What are your health goals?
*
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3. Medical History
How was your childhood health?
Any past or future surgeries (include date)?
Any significant trauma (auto accidents, falls, emotional, sexual)?
List all medications you currently take and reason for taking it:
Have you had any long-term or frequent use of antibiotics? Please describe:
Do you currently suffer from any of the following conditions?
Acne
Acid reflux
Allergies
Anemia
Asthma
Athlete's foot
Autoimmune
Blood transfusion
Bone spurs
Bone fractures
Bronchitis
Bulging disc
Bursitis
Cancer
Candidiasis
Carpal tunnel
Colitis
COPD
Crohn's disease
Dementia
Degenerating disc
Depression
Diabetes
Drug reaction
Eating disorder
Eczema
Epilepsy
Fibromyalgia
Frequent colds
Fungal infection
GERD
Gout
Heart attack
Heart disease
Hemorrhoids
Hepatitis
High blood pressure
HIV/Aids
Hyper thyroid
Hypo thyroid
IBS
infertility
Jaundice
Joint swelling
Kidney stones
Lots of cavitites
Low blood pressure
Measles
Meniere's disease
Mental breakdown
Migraine
Multiple sclerosis
Mumps
Neuropathy
Obesity
Osteoarthritis
Osteopenia
Osteoporosis
Parasites
Plantar fasciitis
Pneumonia
Premature graying
Psoriasis
Rash
Rheumatoid arthritis
Scoliosis
Seizures
Skin condition
Spinal stenosis
Spondylolisthesis
STD
Teeth grinding
Tendonitis
Tension headache
Tinnitus
TMJ dysfunction
Tuberculosis
Ulcer
Vertigo
Please list any other conditions I should be aware of:
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4. Chinese Diagnosis
In order to properly diagnose your condition, check ALL symptoms you currently have (even if you don't think it relates to your current health condition). Some symptoms may be listed more than once or seem unrelated to the organ system.
Qi Deficiency/Stagnation
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Fatigue
General weakness
Low voice
Shortness of breath
Spontaneous sweating
Shallow breathing
Laziness to speak
Local pain
Abdominal distention
Feeling of oppression
Distending pain
Painful swollen breasts
Rectal pressure
I have none of the above symptoms
Blood Deficiency/Stagnation/Heat
*
Pale complexion
Lusterless complexion
Pale lips
Dry skin
Dry, brittle nails
Lifeless hair
Hair loss
Dizziness
Blurry vision
Palpitations
Insomnia
Numbness in extremities
Stiffness
Dark facial complexion
Painful, hard swellings
Swollen glands
Stabbing pain in fixed location
Bruise easily
Excess menstrual bleeding
Frequent nose bleeds
Blood in stools
Blood in urine
I have none of the above symptoms
Respiratory System (Lungs)
*
Asthma
Sinus infection
Weak breathing
Shortness of breath
Cough
Weak voice
Spontaneous sweating
Aversion to cold
Weakened immunity
Frequent colds
Ear ache
Dry mouth/throat
Hoarse voice
Fever
Chills
Night sweats
Thirst
Headache
Body aches
Sneezing
Stuffy nose/chest
Runny nose
Itchy throat
I have none of the above symptoms
Gastrointestinal System (Large Intestine)
*
Abdominal pain
Constipation
Diarrhea
Loose stools
Mucus/blood in stools
Foul stool
Burning anus
Scanty, dark urine
Pale urine
Fever and sweating
Thirst without the desire to drink
Heavy sensation in body or limbs
Fullness in chest or body
Borborygmus (stomach rumbling)
I have none of the above symptoms
Digestion (Spleen)
*
Poor appetite
Bloating after eating
Fatigue
Abdominal pain
Weakness of limbs
Loose stools
Nausea
Vomiting
Heavy feeling in head and limbs
Undigested food in stools
Cold limbs
Edema
Uterine prolapse
Hemorrhoids
Varicose veins
Blood in stool/urine
Excess menstrual bleeding
Cold feeling in belly improved by warmth
No thirst
No desire to drink
Foul-smelling stools
Burning sensation in anus
Scanty, dark-colored urine
Low-grade fever
Whole head headache
I have none of the above symptoms
Digestion (Stomach)
*
Abdominal pain
Fullness after eating
Pain after eating
Vomit after eating
Lack of appetite
Vomit of dark blood
Vomit of clear fluid
Lack of appetite
Lack of taste
Loose stools
Blood in stools
Constipation
Fatigue in AM
Weak limbs
Prefer warm drinks and foods
Lack of thirst
Cold limbs
General fatigue
Feeling warm in PM
Dry mouth
Burning in stomach
Sour regurgitation
Bad breath
Thirst for cold drinks
Constant hunger
Gum swelling, pain, and bleeding
Belching
Hiccough
I have none of the above symptoms
Cardiovascular System (Heart)
*
Palpitations
Panic attacks
Dizziness
Pale complexion
Lassitude of spirit
Shortness of breath
Spontaneous sweating
Oppression in chest
Chest pain
Cold extremities
Feeling of cold
Mental restlessness
Easily startled
Insomnia
Profuse dreaming
Night sweats
Heat in palms, soles, and chest
Ulcers of mouth or tongue
Blood in urine
I have none of the above symptoms
Digestion (Small Intestine)
*
Abdominal pain
Tongue ulcers
Scanty, dark, painful, or bloody urination
Throat pain
Thirst
Desire for warm liquids
Sudden hearing loss
Abdominal pain that radiates to low back
Pain worse with pressure
Pain relieved by warmth and pressure
Flatulence that relieves pain
Borborygmus (stomach rumbling)
Testicular pain
Vomiting
Constipation
Diarrhea
Abdominal distention
Pale and copious urination
I have none of the above symptoms
Liver
*
Abdominal distention
Fixed and stabbing abdominal pain
Sensation of lump in the throat
Alternating constipation and diarrhea
Irregular elimination
Constipation with dry stools
Acid reflux
Jaundice
Nausea and vomiting
Dark yellow urine
Vomit of blood
Loss of appetite
Pain in the scrotum/testes
Straining of the testes
Contraction of scrotum
Numbness of the limbs
Muscular weakness
Muscle spasms
Muscle cramps
Hypertension
Red face and eyes
Tinnitus or deafness
Temporal headache
Migraine
Dizziness
Blurred vision or floaters
Insomnia with dream disturbed sleep
irregular menstruation
Painful menstruation
Scanty menstruation
Premenstrual breast tenderness
PMS
Dark, clotted menstrual blood
I have none of the above symptoms
Gall Bladder
*
Pain/distention along sides of abdomen
Nausea
Vomiting
Inability to digest fats
Yellow complexion
Bile backed up
Scanty, dark yellow urine
Fever
Thirst without the desire to drink
Bitter taste
Dizziness
Blurred vision
I have none of the above symptoms
Kidney
*
Slow development as a child
Poor skeletal development
Brittle bones
Sore/weak low back and knees
Premature graying
Hair loss
Premature aging
Dental and teeth problems
Dizziness
Deafness
Tinnitus
Low sex drive
Infertility
Impotence or frigidity
Premature ejaculation
Chills and aversion to cold
Cold limbs
Swollen hands and feet
Lethargy
Coldness in the lumbar region
Copious, clear urine
Frequent urination
Incontinence
Reduced urine and edema
Loose stool, especially in AM
Hot palms and/or soles
Red cheek bones
Night sweats
Afternoon fever
Constipation
Dark urine
Thirst
Nocturnal emission (especially with dreams)
I have none of the above symptoms
Bladder
*
Lower back pain
Dark yellow urine
Pale cloudy urine
Stones in urine
Frequent or urgent urination
Pain or burning during urination
Difficult urination
Incontinence
Heavy sensation in lower abdomen
Fever
Thirst
Frequent, pale, and copious urination
I have none of the above symptoms
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5. Body Temperature
Check all that apply:
*
Feel cold often
Dislike the cold
Cold hands
Cold feet
Feel hot often
Dislike the heat
Afternoon flushes
Night sweats
Perspire easily
Lack of perspiration
Heat in soles, hands, and chest
Normal
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6. Stress Level
How would you rate your overall stress level:
Acute (occurs for short periods of time causing anger, irritability, anxiety, periods of depression, headache, pain, stomach upset, dizziness, shortness of breath, heart palpitations, hypertension, and bowel disorders).
Episodic (will last longer than acute stress causing periods of intermittent depression, anxiety disorders, emotional distress, ceaseless worrying,and persistent physical symptoms similar to those found in acute stress.
Chronic (brought on by long-term exposure to stressors that cause more serious and chronic health issues such as chronic fatigue, clinical depression, sleep disorders, high blood pressure, auto-immune disorders, etc.).
Mild (symptoms are mild and dissipate quickly. No long term effects).
Do you receive weekly counseling/psychotherapy?
Do you regularly do any awareness practices (meditation, yoga, tai chi, prayer, affirmations, etc.)?
What are the primary causes of stress in your life?
How would you describe your current state of mind?
Happy
Sad/grieving
Worry
Fearful
Over-excitement
Depression
Anxiety
Insomnia
Sluggish thinking
Foggy thinking
Poor memory
Mental restlessness
Frustrated
Poor concentration
Irritability
Difficult making a decision
Nervous
Timid
Easily startled
Lack of courage and initiative
Frequent sighing
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7. Sleep
Do you sleep well?
*
All the time
Most of the time
Some of the time
Hardly ever
Do you fall asleep easily?
Yes
No
Sometimes
Do you feel rested when you wake up?
Yes
No
Sometimes
Do you wake during the night?
Yes
No
Sometimes
Do you fall back to sleep easily
Yes
No
Sometimes
Do you have lots of dreams?
Yes
No
Sometimes
Do you have frequent nightmares?
No
Yes
Do you have sleep apnea?
Yes
No
Do you get night sweats?
Yes
No
Do you nap during the day?
Yes
No
Sometimes
Do you drink caffeine?
Yes, daily
No
On occasion
Does physical pain keep you from sleeping well?
Yes
No
On occasion
Do any of your medications keep you from sleeping well?
Yes
No
Not sure
Do you take any prescription sleep aids?
Yes
No
Do you get up at night to urinate?
Yes
No
On occasion
Average hours of sleep per night:
*
On a scale of 1 to 10 (10 being best), how would you rate your energy level?
*
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8. Neuromuscular Pain
Where is the primary area of pain in your body?
Describe your pain:
Dull
Achy
Sharp
Cramping
Burning
Numbness
Fixed location
Moves around
Refers to other areas
Stiffness
Swelling
Throbbing
Constant
Comes and goes
Worse in AM
Worse in PM
Worse in cold weather
Worse in hot weather
Does heat make it feel better?
Yes
No
Does cold make it feel better?
Yes
No
Have you used any self-care techniques to relieve your pain (cold/heat packs, self massage, stretching, etc.)?
Have you received any physical therapy or other types of therapy for your pain? Please describe:
Do you take any prescription drugs or over-the-counter drugs for your pain? Please specify:
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9. Physical Activity
Do you exercise? How frequently and for what duration?
*
What types of exercise?
Do you like to exercise?
What kind of work do you do? Hours per week?
How many hours do you spend at the computer daily?
How many hours of TV you watch daily?
What physical activities do you enjoy (walking, swimming, yoga, etc.)?
Are there any reasons and/or conditions that prevent you from exercising regularly? Please specify:
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10. Diet and Nutrition
How is your appetite and how many meals do you eat daily?
How often do you have a bowel movement?
Are you thirsty and how much water do you drink per day?
Do you prefer cold or hot beverages?
Do you drink caffeine and how much daily?
List other beverages you drink including juice, rice milk, almond milk, tea, etc?
What dairy products do you eat/drink?
Are you a vegetarian or vegan? Please list sources of protein:
What percentage of your diet is organic:
Do you have any particular cravings?
List any food allergies or sensitivities:
Do you eat regularly at fast food restaurants?
How often do you eat out?
Every day
Frequently
On occasion
Rarely
Do you eat a lot of processed food?
Do you eat late at night or before going to bed?
Do you chew your food well?
Do you think you get enough fresh fruits, vegetables, and whole grains daily?
Do you drink alcohol and how much?
Do smoke cigarettes and how many daily?
Do you take any other recreational drugs?
How would you describe your diet:
Unhealthy
Fair
Good
Excellent
On a scale of 1 to 10 (10 being best), how would you rate your cooking skills:
Are you ready and willing to make changes to your diet if need be?
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11. Men's Health
Check all that apply to you:
Erectile dysfunction
Low libido
Testicular pain
Premature ejaculation
STD
Prostrate issues
Infertility
Varicocele
Any other issues I should be aware of? Please specify:
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12. Women's Health
Are you currently pregnant or trying to get pregnant? If pregnant, how many weeks are you?
Are your periods regular (26-32 days)? If not, please describe:
How many days does your period last?
Please check any of the folliwing that apply to you:
Birth control pills
Painful periods
Heavy flow
Clots
Anemia
Bruise easily
Scanty flow
PMS
Premenstrual spotting
Mid-cycle sppotting
Irritability
Insomnia
Breast tenderness
Breast cancer
Breast lumps
Fibroids
Migraine
Infertility
Endometriosis
PCOS
Vaginal discharge
Yeast infections
Menopause
Hot flashes
Night sweats
STD
Hormone replacement therapy
Are you currently going through fertility treatment? Please describe:
How many pregnancies have you had? Any miscarriages?
Are you in perimenopause or menopause? Are you having any issues?
Menstrual Chart (please fill in)
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7
Color of blood:
• Red
• Dark
• Pale
• Rust
• Purple
Amount of flow:
• Light
• Med
• Heavy
Clots:
• Small
• Med
• Large
• Purple
• Red
Cramps:
• Mild
• Med
• Severe
Pain:
• Head
• Ovary
• Back
• Breast
Bloating
Nausea
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